- 1. Researches payer denials related to medical necessity, coding, etc resulting in denials and delays in payment.
- 2. Evaluates Outpatient Clinical denials against medical record documentation, the coding of the encounter , payer policies and contracts, and coverage determinations to determine the viability of an appeal
- 3. Compiles the supporting documentation by working in partnership with internal departments and uses technology, drafts detailed, customized appeal letters to payers in accordance with Medicare, Medicaid, Commercial, and YNHHS policies and procedures.
- 4. Ensures and tracks receipt of appeals and timely follow-up with all submissions until determination is made.
- 5. Identifies payer denial trends, triage discrepancies, ongoing medical necessity, coding, or service issues, and collaborate or escalate appropriately for resolution.
- 6. Collaborate internally to provide educational opportunities derived from common themes discovered through the appeal process in an effort to prevent future denials .
- 7. Track key denial data as they relate to departmental metrics and performance. Develop and maintain key metrics report including the identification of trends, action plans, etc. Attend organizational committees to present data, as required.
- 8. Communicate directly with payer and coordinate meetings with contracting and payers as needed to support appeals process.
- 9. Perform other duties as assigned.
-
OP Clinical Denial Specialist
4 weeks ago
Yale New Haven Health New Haven, United StatesOverview: · To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and p ...
-
Denial Management Specialist
1 week ago
Middlesex Hospital Middletown, United StatesDenial Management Specialist · Full-Time/40 Hours · The Smarter Choice for your Career · Come join one of Connecticut's Top Workplaces, and a Magnet designated organization At Middlesex Health, we have a unique combination of award-winning talent, world-class technology, and p ...
-
Ada Assistant
3 weeks ago
Yale New Haven Health New Haven, United StatesOverview: To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and prof ...
-
Accounts Receivable Specialist
2 weeks ago
New England Orthotic and Prosthetic Systems Branford, United States**Overview**: The Accounts Receivable Specialist will assist in ensuring that the company receives payment for goods and services offered to clients. **Responsibilities Include but are not limited to**: · - Prepares, posts, verifies, and records customer payments and transactions ...
-
Ar Recovery Specialist-remote
3 weeks ago
Adelfi Medical Billing Solutions Milford, United States**Job Title**: Account Receivable Recovery Specialist · **Company**: Adelfi Medical Billing Solutions · **Position Type**: Full-time · **Qualifications**: · **Responsibilities**: · ? Manage claim submission process end-to-end through submission, response, · and final payment · ? ...
-
Chubb New Haven, United StatesChubb is currently seeking a Workers' Compensation Lost Time Claim Specialist for our Northeast, New York, and New Jersey Region. The successful applicant will be handling claims from Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, and New Jersey. The ...
-
Clinical Revenue Management Specialist I
4 days ago
Yale New Haven Health New Haven, United States PermanentOverview: · To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and p ...
-
Clinical Revenue Management Specialist I
3 weeks ago
Yale New Haven Health New Haven, United StatesOverview: · To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and pr ...
-
Billing Specialist
3 weeks ago
Southwest Community Health Center Bridgeport, United States**SUMMARY**: The Billing Specialist is responsible for overseeing the billing process for the patients of Southwest Community Health Center, Inc. Their duties include processing payments on behalf of our patients' insurance carriers / self-pay patients while maintaining an organi ...
-
Medical Billing Specialist
1 week ago
Hunters Ambulance Service Meriden, United States**Description** · **Job Schedule**: Full Time · **Standard Hours**: 40 · **Job Shift**: Shift 1 · **Shift Details**: · Work where every **moment matters**. · Every day, over 35,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing ...
-
Utilization Management Specialist
1 week ago
Saint Francis Health System New Haven, United StatesCurrent Saint Francis Employees - Please click HERE to login and apply.Full Time11p - 7aHours: Monday - Friday | 11:00pm - 7:00amJob Summary: The Utilization Management Specialist (LPN) will analyze patient records to determine legitimacy of hospital admission, treatment, and app ...
-
Utilization Management Specialist
1 week ago
Saint Francis Health System New Haven, United StatesCurrent Saint Francis Employees - Please click HERE to login and apply. · Full Time · 11p - 7a · Hours: Monday - Friday | 11:00pm - 7:00am · Job Summary: The Utilization Management Specialist (LPN) will analyze patient records to determine legitimacy of hospital admission, tr ...
-
Utilization Management Specialist
1 week ago
Saint Francis Health System New Haven, United StatesCurrent Saint Francis Employees - Please click HERE to login and apply. · Full Time · 3p - 11p · Hours: Monday - Friday | 3:00pm - 11:00pm · Job Summary: The Utilization Management Specialist (LPN) will analyze patient records to determine legitimacy of hospital admission, tr ...
-
Patient Account Analyst
4 days ago
Yale New Haven Health New Haven, United States PermanentOverview: · To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and p ...
-
Chubb New Haven, United StatesJob Description · Chubb is currently seeking a Workers' Compensation Lost Time Claim Specialist for our Northeast, New York, and New Jersey Region. The successful applicant will be handling claims from Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, a ...
-
Revenue Cycle Specialist
2 days ago
Refocus Eye Health Waterbury, United StatesThe Revenue Cycle Specialist is primarily responsible for patient revenue management support throughout the revenue cycle, to include but not limited to: Claims Management, Accounts Receivable, Cash Posting and Denials Management. · **Essential Duties**: · May be required to do o ...
-
Behavioral Health Coder/Billing Specialist
2 weeks ago
Fair Haven Community Health Care New Haven, United StatesJob Description · Job DescriptionFair Haven Community Health Care · FHCHC is a forward-thinking, dynamic, and exciting community health center that provides care for multiple generations at nearly 140,000 office visits in 19 locations. Overseen by a Board of Directors, the major ...
-
Financial Clearance Specialist
6 days ago
Stony Brook University Hospital Stony Brook, United States**Financial Clearance Specialist - Cancer Center** · **Position Summary** · The **Financial Clearance Specialist** is responsible for ensuring that payers are prepared to reimburse Stony Brook University Hospital Cancer Services for scheduled services in accordance with the payer ...
-
Director, RN Case Management
1 week ago
Yale-New Haven Health Milford, United StatesOverview · To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and profe ...
-
Advanced Radiology Consultants Shelton, United StatesJob Description · Job DescriptionJoin our Culture of Caring · Advanced Radiology is one of the largest independent radiology practices in the tri-state area with the most experienced radiologists. We look for team members who want to grow and be professionally challenged, while ...
OP Clinical Denial Specialist - New Haven, United States - Yale-New Haven Health
Description
Overview
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values.
These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The OP Clinical Denial Specialist supports the organization by reducing financial liability and recovering lost revenue for coding and medical necessity denials.
managing medical denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation and the medical policies of the payor, submitting appeals in a timely manner, and identifying/resolving denial trends to mitigate potential loss.
The OP Clinical Denial Specialist will also handle audit-related / compliance responsibilities and other administrative duties as required.This individual works closely with colleagues within the organization and with managed care payers to resolve issues and expedite reimbursement on overturned appeals.
EEO/AA/Disability/VeteranResponsibilities
EDUCATION
Two (2) years of college or equivalent with familiarity with medical terminology and anatomy. Knowledge of coding , billing and the revenue cycle. Working knowledge of human anatomy and physiology, Disease process , demonstrated knowledge of medical terminology and the medical record.
EXPERIENCE
Three to five years of coding and/or billing experience required. Previous experience with governmental and managed care denial/appeal process including familiarity with RAC. Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, Epic HB billing knowledge preferred.
LICENSURE
Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) or similar certification is required, or must be obtained within a year of hire.
SPECIAL SKILLS
In-depth knowledge of documentation elements within the medical record. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures.
Ability to analyze and resolve coding and medical necessity payer denials through in depth knowledge of payer policies and appeal procedures.
Previous experience with clinical denials and appeals for all payers is preferred.YNHHS Requisition ID
110180
